DIAN Observational Biospecimen Request Form

Please read the terms and obligations of using DIAN data. By submitting this request, you are acknowledging your acceptance of and willingness to comply with the terms stated.

Investigator Information

Date of Request*

First Name*

Enter the investigator's first name.

Last Name*

Enter the investigator's last name.

Institution*

Enter the investigator's institution.

Email Address*

Enter the investigator's email address.

Phone Number*

Enter the investigator's phone number.

Are you a member of the DIAN Steering Committee?*

Yes

No

Project Title*

Project Aim 1*

Please provide up to 4 concise aims for your project (300 character limit per aim). At least one aim must be provided. Do not indicate: "see attached". If no aims are entered, your request will not be processed.

Project Aim 2

Project Aim 3

Project Aim 4

Source of Support

Type of Funding*

Please do not list here the DIAN grant or the DIAN PI (Morris); please provide information specific to this request.

Sponsor*

Grant Title*

Grant Number*

Principal Investigator*

Faculty Mentor

If you are a student, graduate student or fellow, please provide the name of your faculty mentor on this project.

Purpose Information

Purpose*

What is the purpose of this request? Check all that apply.

Current or planned research

Preliminary feasibility

Data exploration

Grant application

Journal publication

Abstract submission

Clinical trial

Other

Do you have IRB approval?*

IRB Approval Number

IRB Approval Date

Date Resources Needed

Date of Estimated Completion

Is it okay to include your data in the DIAN Central Neuroimaging Data Archive?*

If you selected "No" to this question, provide your reasons in your submitted Research Rationale (see below).

Yes

No

Diagnostic Categories Requested

Submit up to 5 individual requests per form submission below:
Please be aware that sample sizes may be subject to availability of ADRC materials, resources, and staff.
Key: DAT = Dementia of the Alzheimer Type

Number of Subjects

CDR

Clinical Diagnosis

Mutation Type

Neuropathological Diagnosis

(based on autopsy)

Number of Subjects

CDR

Clinical Diagnosis

Mutation Type

Neuropathological Diagnosis

(based on autopsy)

Number of Subjects

CDR

Clinical Diagnosis

Mutation Type

Neuropathological Diagnosis

(based on autopsy)

Number of Subjects

CDR

Clinical Diagnosis

Mutation Type

Neuropathological Diagnosis

(based on autopsy)

Number of Subjects

CDR

Clinical Diagnosis

Mutation Type

Neuropathological Diagnosis

(based on autopsy)

Type of Tissue Requested
Please specify the following information about your requests above:

HIPAA Section

Will you be sharing/sending these materials/data to anyone outside of your immediate research team/lab/office?*

Due to HIPAA regulations and Center policies, the approval of this request only covers the use of materials/data by your laboratory/office/staff. If the materials/data are to be shared or analyzed outside your laboratory, please inform us now. Violations of HIPAA regulations can carry significant penalties including fines and prosecution.

Yes

No

Please identify who will receive our research materials and for what reason in the text field below:

Research Rationale:
Please send your research rationale as an attachment to karchc@wustl.edu. Your rationale should include the following information and not exceed 2 pages (references and figures excluded): purpose, background and preliminary data, methods, inclusion and exclusion criteria, analytic plan, and sample size justification.

Biosketch:
Please also send an NIH Biosketch or brief curriculum vitae to karchc@wustl.edu.

Code Access Agreement:
All investigators accessing or receiving DIAN data or tissue must return a signed code access agreement prior to receipt of data/tissue. Please fill out this form and return it to karchc@wustl.edu.

File Upload

If don't want to email your files and have them ready, you can upload your Research Rationale, Biosketch and Code Access Agreement files by attaching them to this form. The maximum size limit for all files combined is 16MB.